NURS 270 Unit 5

A Patient tells the nurse that he does not want to develop the same heart problems that his parents experienced. Which of the following should the nurse instruct this client? 1. Avoid cigarette smoking 2. Limit fluid intake 3. Wear elastic hose 4. Limit exercise to 15 minutes a day

1. Avoid cigarette smoking Rationale: • The one intervention that would help the client prevent the onset of cardiovascular disease would be to avoid cigarette smoking. Limiting fluids and wearing elastic hose are not known to prevent the onset of cardiovascular disease. Limiting exercise to 15 minutes a day may also not be enough exercise to prevent the onset of cardiovascular disease. • Nursing Process: Implementation • Cognitive Level: Applying • Client Need: Health Promotion and Maintenance • Learning Outcome: 6. Explain management of cardiovascular health and prevention of cardiovascular illness.

A Patient asks the nurse how he developed chronic obstructive pulmonary disease (COPD). Which of the following would be the best response for the nurse to make to this client? 1. Cigarette smoking is the number one cause of COPD. 2. COPD is caused from asthma. 3. COPD is caused from working in an industrial environment. 4. Once diagnosed with COPD, quitting smoking won't help the disease.

1. Cigarette smoking is the number one cause of COPD. • Rationale: • The number one risk factor for the development of COPD is cigarette smoking. Individuals with asthma can develop COPD; however, it is not the number one cause of the illness. COPD can develop from working in an industrial environment; however, the chance of that occurring is small. Once diagnosed with COPD, quitting smoking will help, and the client should be encouraged to do so to stop the progression of the disease. • Learning Outcome: 2. Identify risk factors associated with chronic obstructive pulmonary disease.

Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? a. Respiratory rate of 22 breaths/minute b. Dilated and reactive pupils c. Urine output of 40 ml/hour d. Heart rate of 100 beats/minute

Answer A. In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? a. Simple mask b. Non-rebreather mask c. Face tent d. Nasal cannula

Answer B. A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent and nasal cannula — deliver lower levels of FIO2.

Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review? a. Fluid intake for the last 24 hours b. Baseline arterial blood gas (ABG) levels c. Prior outcomes of weaning d. Electrocardiogram (ECG) results

Answer B. Before weaning a client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician. b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site.

Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a. helping him communicate. b. keeping his airway patent. c. encouraging him to perform activities of daily living. d. preventing him from developing an infection.

Answer B. Maintaining a patent airway is the most basic and critical human need. All other interventions are important to the client's well-being but not as important as having sufficient oxygen to breathe.

A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest? a. Cyanosis b. Hypotension c. Paradoxical chest movement d. Dyspnea, especially on exhalation

Answer C. Flail chest results from fracture of two or more ribs in at least two places each. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a telltale sign of flail chest.

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds

Answer C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH, 5.0; PaCO2 30 mm Hg b. pH, 7.40; PaCO2 35 mm Hg c. pH, 7.35; PaCO2 40 mm Hg d. pH, 7.25; PaCO2 50 mm Hg

Answer D. In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?

Use a pulse oximeter to determine oxygen saturation. Explanation: A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client's need for oxygen therapy. Although the client may feel the need for oxygen during periods of dyspnea, this is not a reliable way of determining the client's need. Fatigue may be due to other factors besides oxygenation levels. Evaluating the client's hemoglobin level can provide an indication that the client may have less oxygen-carrying capacity but is not a reliable indicator of oxygen need.

As you observe Mr. Fenske, you recall that chronic obstructive pulmonary disease (COPD) is generally characterized by progressive reduction in bronchial airflow. The underlying pathophysiology may involve: Select all that apply a. air trapping in distal air spaces b. airway inflammation and excessive mucous c. chronic infection of the alveoli d. escape of air from the lung into the pleural space

a, b

Which considerations are critical for the nurse to make when assigning a room to a client with community acquired pneumonia (CAP)? Select all that apply a. Mr. Hannigan's confusion b. Infection control c. Mr. Hannigan's gray skin color d. The high anxiety level of Mr. Hannigan's family members

a, b

The respiratory therapist is notified about the HCP's prescription for drawing arterial blood gases (ABGs) on Mr. Hannigan. Which actions should be implemented after the specimen is drawn? Select all that apply a. Arrange for immediate transport of the specimen to the laboratory b. Ensure an airtight seal for the blood specimen container c. Apply direct pressure to the puncture site d. Position Mr. Hannigan in the Fowler's position e. Check Mr. Hannigan's blood pressure

a, b, c

You are often required to obtain sputum specimens from patients. Which of the following should be carried out when obtaining a sputum specimen? Select all that apply a. A sterile specimen container should be used b. A specimen should be coughed up from the lungs c. A morning specimen is preferred Correct d. A specimen should be obtained before any mouth cleansing

a, b, c

Besides assessment of respirations, which of the following are indicated at this time? Select all that apply a. Auscultation of breath sounds b. Observation of chest movement c. Assessment of orientation d. Assessment of skin color e. Determination of vital capacity

a, b, c, d

Mrs. Frank has already had preoperative teaching. Which of the following should you review? Select all that apply a. Deep breathing and coughing b. Leg exercises c. Incentive spirometry d. Frequent turning e. Urinary catheterization f. Chest tube drainage g. Pain management

a, b, c, d, f, g

Under which of the following conditions is it acceptable to clamp a chest tube? Select all that apply a. To locate an air leak source b. To change a chest drainage system c. To stop loss of large amounts of bright red blood from a chest tube d. To determine whether or not it is time to remove a chest tube e. To assess a complaint of severe pain at a chest tube insertion site

a, b, d

Which of the following factors, identified as part of Mr. Fenske's health history, may have predisposed him to emphysema? Select all that apply a. History of smoking two packs per day for 40 years . b. A family history of chronic obstructive pulmonary disease (COPD) c. A history of allergies d. Employment as a carpenter

a, b, d

With regard to chest tube removal, which of the following are correct? Select all that apply a. A patient will be more comfortable if an analgesic is administered before the procedure b. An occlusive dressing will help prevent entry of air after the chest tube has been removed c. The dressing applied after a chest tube is removed should be changed 3-4 times per day for the first 48 hours d. After a chest tube is removed, a chest x-ray is obtained to insure that air has not entered the pleural space and that the lung is expanded e. A patient is asked to inhale deeply and hold his breath for chest tube removal

a, b, d, e

You are conducting a physical assessment of Mr. Hannigan. Which findings would the nurse expect? Select all that apply a. lung crackles b. tachypnea c. hoarseness d. clubbing of fingers e. nasal flaring

a, b, e

Although Mr. Fenske's respiratory status has improved, you continue to observe him for signs of hypoxia. When assessing Mr. Fenske for hypoxia, you observe for: Select all that apply a. restlessness b. bradycardia c. cyanosis d. fever

a, c

Which of the following clinical signs/symptoms are common in persons with chronic obstructive pulmonary disease (COPD)? Select all that apply a. Increasing shortness of breath b. hemoptysis c. cough d. weight gain

a, c

Having worked on the Chest Surgery Unit for over a year, you've learned a lot about cancer of the lung. Which of the following are true with regard to cancer of the lung? Select all that apply a. For men and women combined, it is the leading cancer-related cause of death b. For women, it is the most frequently-occurring cancer c. For both men and women, only a small percentage of patients live five or more years after diagnosis d. For both men and women, long-term survival is more likely if the cancer is detected early

a, c, d

Which of the following are usually indicated in preparation for bronchoscopy with a flexible fiberoptic bronchoscope? Select all that apply. a. NPO prior to procedure b. Cleansing enema night before procedure c. Explanation of the procedure d. Removal of dentures e. Administration of a sedative f. Instruction in pursed lip breathing g. Written consent

a, c, d, e, g

Mr. Hannigan will be discharged very soon. Which discharge instructions are indicated? Select all that apply a. Take frequent rest periods as needed b. Stop antibiotics when feeling better c. Avoid carbonated drinks d. Drink lots of fluid each day e. Remain indoors while taking levofloxacin

a, d

The physician performs a thoracentesis on a patient with a right pleural effusion. In preparing the patient for the procedure, the nurse positions the patient Answers: a. on his left side with his right arm extended above his head. b. sitting upright with his arms supported on an overbed table. c. supine with the head of the bed elevated 45 degrees. d. on his left side in Trendelenburg's position with both arms extended.

b

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy? Answers: a. Determining the need for replacement of the tracheostomy tube b. Suctioning the tracheostomy when needed c. Educating the patient about self-care of the tracheostomy d. Assessing the patient's risk for aspiration

b

Your assessment of Mr. Fenske does not reveal signs of right ventricular heart failure. However, you know that signs and symptoms of right ventricular heart failure can include: Select all that apply a. clubbing of the fingers b. dependent pedal edema c. distended neck veins d. hepatomegaly

b, c, d

Which nursing measures should you incorporate into Mr. Hannigan's care? Select all that apply a. Tepid sponge baths b. Frequent position changes c. Encourage oral fluids d. Use of side rails e. Bed in low position f. Assist with activities of daily living g. Preparation for thoracentesis

b, c, d, e, f

Assessing for signs of hypoxia is especially important with patients who have respiratory problems or have had lung surgery. Cyanosis is most evident in specific body areas. When checking for evidence of cyanosis, which of the following body areas should be observed? Select all that apply a. Axillae b. Nailbeds c. Lips d. Palms of the hands e. Mucous membranes f. Sternum g. Earlobes

b, c, d, e, g

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) Answers: a. Immune system b. Neurologic system c. Pulmonary system d. Endocrine system e. Cardiovascular system f. Hepatic system

b, c, e

While Mrs. Frank is receiving morphine, vital signs are closely monitored. Which of the following vital sign changes could indicate that Mrs. Frank was receiving too much morphine? Select all that apply a. Increasing blood pressure b. Decreasing blood pressure c. Increasing respiratory rate d. Decreasing respiratory rate

b, d

After bronchoscopy, checking for complications is a priority. To determine if any complications are present, you assess for which of the following? Select all that apply a. Hematuria b. Dyspnea c. Weak pedal pulses d. Hemoptysis e. Cyanosis

b, d, e

A patient with respiratory disease has a shift to the left in the oxygen-hemoglobin dissociation curve. The nurse recognizes that this finding indicates that Answers: a. less oxygen is dissolved in plasma but is readily released to the tissue. b. less oxygen is dissolved in plasma and is not readily released to the tissue. c. more oxygen is dissolved in plasma and is readily released to the tissue. d. more oxygen is dissolved in plasma but is not readily released to the tissue.

d

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? Answers: a. The student preoxygenates the patient for 1 minute before suctioning. b. The student applies suction for 10 seconds while withdrawing the catheter. c. The student inserts the catheter about 5 inches into the tracheostomy tube. d. The student puts on clean gloves and uses a sterile catheter to suction.

d

The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use? Answers: a. The patient became very short of breath an hour before coming to the hospital. b. The patient has been taking acetaminophen 650 mg every 6 hours for chest-wall pain. c. The patient says there have been no acute asthma attacks during the last year. d. The patient has been using the albuterol inhaler more frequently over the last 4 days.

d

Which of the following interventions would be appropriate for a Patient with the nursing diagnosis of excess fluid volume? 1. Assess respiratory status and lung sounds every 4 hours and prn 2. Provide oxygen as prescribed 3. Monitor brain natriuretic peptide (BNP) level 4. Provide information about activity upon discharge

1. Assess respiratory status and lung sounds every 4 hours and prn • Rationale: • Interventions appropriate for the nursing diagnosis of excess fluid volume include assessing respiratory status and lung sounds every 4 hours and prn. Providing oxygen and monitoring BNP level are intervention appropriate for the diagnosis of decreased cardiac output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of activity intolerance. • Nursing Process: Planning • Cognitive Level: Applying • Client Need: Physiological Integrity • Learning Outcome: 5. Create a plan of care for individuals with cardiomyopathy and their family members.

A postpartum patient recovering from a deep vein thrombosis is being discharged. About which of the following topics should the nurse instruct this client? (Select all that apply.) 1. Avoid crossing the legs 2. Avoid prolonged standing or sitting 3. Take frequent walks 4. Take a daily aspirin dose of 650 mg 5. Avoid long car trips

1. Avoid crossing the legs 2. Avoid prolonged standing or sitting 3. Take frequent walks. • Rationale: • The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should be instructed also to avoid prolonged standing or sitting, which contributes to venous stasis. The client should also be instructed to take frequent walks to promote venous return. The client should not be instructed to take a daily aspirin because it will increase anticoagulant activity and could interact with other medication prescribed for the treatment of the deep vein thrombosis. The client does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips. • Nursing Process: Implementation • Cognitive Level: Applying • Client Need: Physiological Integrity • Learning Outcome: 5. Create a plan of care for individuals with deep venous thrombosis and their families.

An elderly female patient arrives in the emergency department complaining of fatigue, nausea, vague complaint of intermittent chest discomfort, and not sleeping well. The nurse would interpret these findings as symptoms of: 1. Cardiac disease. 2. Pancreatic disease. 3. Normal changes of aging. 4. Signs of anemia.

1. Cardiac disease. • Rationale: • Many elderly women complain of vague symptoms when having a myocardial infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain in the abdominal region. These symptoms are not considered normal changes of aging. Anemia would present with fatigue but not with nausea or chest discomfort. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with common alterations in perfusion.

A Patient is admitted with complaints of shortness of breath of 2 weeks duration. Which of the following laboratory findings would support the finding that the Patient is at risk for an alteration in perfusion? 1. Increased hematocrit 2. Decreased BUN 3. Increased blood sugar 4. Increased sedimentation rate

1. Increased hematocrit. • Rationale: • Hematocrit is the percentage of the blood that is erythrocytes, which contain the hemoglobin that carries oxygen. Long-term hypoxia may result in the body's attempt to increase oxygen-carrying capacity by increasing erythrocyte production. This can lead to an alteration in the client's perfusion. BUN is a measure of blood urea nitrogen, not oxygen-carrying capacity. Increases in blood sugar and sedimentation rate are not directly a measure of oxygenation. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's perfusion status.

The nurse would suspect deep venous thrombosis in a Patient with which of the following assessment findings? 1. Bilateral calf tenderness after walking up a flight of stairs 2. Swelling in one leg with pitting edema 3. Shortness of breath after activity 4. Two plus palpable pedal pulses

2. Swelling in one leg with pitting edema • Rationale: • Swelling in one leg with pitting edema is suggestive of deep venous thrombosis in the vein of the affected leg because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity and two plus palpable pulses are normal. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of deep venous thrombosis.

A Patient diagnosed with a deep vein thrombosis is receiving intravenous heparin. The nurse would identify which of the following as being the priority outcome for this Patient? 1. The Patient will not disturb the intravenous infusion. 2. The Patient will not experience bleeding. 3. The Patient will comply with dietary restrictions. 4. The Patient will keep the right leg elevated on two pillows.

2. The Patient will not experience bleeding. • Rationale: • An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important but not as high a priority as an absence of bleeding. • Nursing Process: Planning • Cognitive Level: Analyzing

The nurse assessing a Patient admitted for a total hip replacement is concerned the Patient would be at risk for thrombus formation because of which of the following? 1. Age 45 years 2. Former cigarette smoker 3. Body mass index (BMI) 35.8 4. Blood pressure 132/88 mmHg

3. Body mass index (BMI) 35.8 • Rationale: • Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the client's weight. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 2. Identify risk factors associated with pulmonary embolism.

The nurse is reviewing the results of laboratory tests conducted on a Patient admitted with a respiratory disorder. The laboratory finding that is the most significant for this Patient would be: 1. Blood pH 7.40. 2. Serum sodium 140 mg/dL. 3. Hemoglobin level 8.3. 4. Oxygen saturation 96%.

3. Hemoglobin level 8.3 • Rationale: • The hemoglobin level affects the amount of oxygen that can be carried in the blood. The low level suggests the client does not have enough red blood cells to provide adequate oxygen for the body. The blood pH of 7.40 is within normal limits. Serum sodium does not impact the oxygen capacity of the body. Oxygen saturation of 96% is within normal limits. • Nursing Process: Assessment • Client Need: Physiological Integrity • Cognitive Level: Analyzing • Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's oxygenation status.

During hospitalization for congestive heart failure, a patient awakens during the night frightened and short of breath. This client most likely is experiencing: 1. Multisystem heart failure. 2. Cardiomyopathy. 3. Paroxysmal nocturnal dyspnea. 4. High-output failure.

3. Paroxysmal nocturnal dyspnea. • Rationale: • Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing multisystem heart failure, cardiomyopathy, or high-output failure. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of heart failure

A patient is admitted with a possible deep vein thrombosis. Nursing interventions should be implemented to prevent which complication? 1. Myocardial infarction 2. Renal failure 3. Pulmonary embolism 4. Pneumonia

3. Pulmonary embolism. • Rationale: • The presence of a deep vein thrombosis is a risk factor for the development of a pulmonary embolism. The nurse should design interventions to help prevent that development. There is less likelihood that the thrombosis would cause myocardial infarction, renal failure, or pneumonia. • Nursing Process: Implementation • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 8. Employ evidence-based caring interventions for an individual with deep venous thrombosis.

The nurse assessing a Patient for symptoms of chronic obstructive pulmonary disease (COPD) realizes that the earliest manifestation to occur in the course of the disease is: 1. Clubbing of the fingers. 2. Cyanotic nail beds. 3. Dysrhythmias. 4. Cough in the morning producing clear sputum.

4. Cough in the morning producing clear sputum • Rationale: • The earliest presenting symptom of COPD is a morning cough with clear sputum unless the client develops an infection, in which case the sputum would become yellow or green in color. With the progression of COPD the body compensates by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers leading to the development of cyanotic nail beds and clubbing of the fingertips. Enlargement and thickening of the right ventricle of the heart often results in dysrhythmias. • Nursing Process: Assessment • Client Need: Physiological Integrity • Cognitive Level: Analyzing • Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of chronic obstructive pulmonary disease..

The nurse is assessing the effectiveness of interventions provided to a patient with chronic obstructive pulmonary disease (COPD). Evidence that care has been effective would be: 1. Patient leaves hospital unit to smoke outside 4 times a day. 2. Patient needs assistance with morning care and meals due to shortness of breath. 3. Patient states family members would prefer he was admitted to a nursing home for continuing care. 4. Patient conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading.

4. Patient conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading. • Rationale: • Evidence that interventions provided to a client with COPD were successful would be the client conducting morning care and ambulating in the room while maintaining an oxygen saturation of 92%. This outcome identifies the client's ability to maintain adequate oxygenation and perform activities of daily living. The client leaving the unit to smoke suggests that the interventions were ineffective. The client who needs assistance with morning care and meals because of shortness of breath needs additional interventions. The client who states that his family would prefer he go to a nursing home may or may not have been positively affected by the interventions; not enough information is provided to know. • Nursing Process: Evaluation • Client Need: Physiological Integrity • Cognitive Level: Analyzing

Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.

Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

Nurse Julia is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which of the following interventions will most likely lower the client's arterial blood oxygen saturation? a. Endotracheal suctioning b. Encouragement of coughing c. Use of cooling blanket d. Incentive spirometry

Answer A. Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improves oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

For a male client with an endotracheal (ET) tube, which nursing action is most essential? a. Auscultating the lungs for bilateral breath sounds b. Turning the client from side to side every 2 hours c. Monitoring serial blood gas values every 4 hours d. Providing frequent oral hygiene

Answer A. For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.

A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration? a. Apnea b. Anginal pain c. Respiratory alkalosis d. Metabolic acidosis

Answer A. Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don't cause metabolic acidosis.

The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a. Place the end of the chest tube in a container of sterile saline. b. Apply an occlusive dressing and notify the physician. c. Clamp the chest tube immediately. d. Secure the chest tube with tape.

Answer A. If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome

Answer A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a. It helps prevent early airway collapse. b. It increases inspiratory muscle strength c. It decreases use of accessory breathing muscles. d. It prolongs the inspiratory phase of respiration.

Answer A. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

A male client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? a. Inflamed lung tissue b. Sudden onset c. Responsiveness to penicillin. d. Elevated white blood cell (WBC) count

Answer A. The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Although most types of pneumonia have a sudden onset, a few (such as anaerobic bacterial pneumonia and mycoplasmal pneumonia) have an insidious onset. Antibiotic therapy is the primary treatment for most types of pneumonia; however, the antibiotic must be specific for the causative agent, which may not be responsive to penicillin. A few types of pneumonia, such as viral pneumonia, aren't treated with antibiotics. Although pneumonia usually causes an elevated WBC count, some types, such as mycoplasmal pneumonia, don't.

For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care? a. Measuring and documenting the drainage in the collection chamber b. Maintaining continuous bubbling in the water-seal chamber c. Keeping the collection chamber at chest level d. Stripping the chest tube every hour

Answer A. The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse should not strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

A male client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client's baseline theophylline level was: a. 10 mcg/mL b. 12 mcg/mL c. 15 mcg/mL d. 18mcg/mL

Answer A. The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may experience frequent exacerbations of the disorder. Although all the options identify values within the therapeutic range, option A is the option that reflects a need for compliance with medication.

The amount of air inspired and expired with each breath is called: a. tidal volume. b. residual volume. c. vital capacity. d. dead-space volume.

Answer A. Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.

A male client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that: a. vancomycin should be infused over 60 to 90 minutes in a large volume of fluid. b. vancomycin may cause irreversible neutropenia. c. vancomycin should be administered rapidly in a large volume of fluid. d. vancomycin should be administered over 1 to 2 minutes as an I.V. bolus.

Answer A. To avoid a hypotensive reaction from rapid I.V. administration, the nurse should infuse vancomycin slowly, over 60 to 90 minutes, in a large volume of fluid. Although neutropenia may occur in approximately 5% to 10% of clients receiving vancomycin, this adverse effect reverses rapidly when the drug is discontinued

A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit: a. Resonant sounds. b. Hyperresonant sounds. c. Dull sounds. d. Flat sounds.

Answer A. When percussing the chest wall, the nurse expects to elicit resonant sounds — low-pitched, hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they're louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax, they may be normal in children and very thin adults. Dull sounds, normally heard only over the liver and heart, may occur over dense lung tissue, such as from consolidation or a tumor. Dull sounds are thudlike and of medium pitch. Flat sounds, soft and high-pitched, are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.

Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true? a. A positive reaction indicates that the client has active tuberculosis (TB). b. A positive reaction indicates that the client has been exposed to the disease. c. A negative reaction always excludes the diagnosis of TB. d. The PPD can be read within 12 hours after the injection.

Answer B. A positive reaction means the client has been exposed to TB; it isn't conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: a. hyperglycemia and glycosuria. b. acute adrenocortical insufficiency. c. GI bleeding. d. restlessness and seizures.

Answer B. Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation.

Nurse Eve formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include: a. drinking more than 1,500 ml of fluid daily. b. being overweight. c. eating a high-protein snack at bedtime. d. eating more than three large meals a day.

Answer B. Conditions that increase oxygen demands include obesity, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals a day may cause fullness, making breathing uncomfortable and difficult; however, it doesn't increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six a day).

A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza? a. Septicemia b. Pneumonia c. Meningitis d. Pulmonary edema

Answer B. Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't associated with influenza.

A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: a. lips. b. mucous membranes. c. nail beds. d. earlobes.

Answer B. Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Administer a prescribed decongestant. b. Instruct the client to breathe into a paper bag. c. Offer the client fluids frequently. d. Administer prescribed supplemental oxygen.

Answer B. The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options — such as administering a decongestant, offering fluids frequently, and administering supplemental oxygen — wouldn't raise the lowered PaCO2 level.

A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Cough b. High-grade fever c. Chills and night sweats d. Anorexia and weight loss

Answer B. The client with tuberculosis usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? a. Inform the physician. b. Continue to monitor the client. c. Reinforce the occlusive dressing. d. Encourage the client to deep-breathe

Answer B. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.

The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing? a. Diaphragmatic breathing b. Use of accessory muscles c. Pursed-lip breathing d. Controlled breathing

Answer B. The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

A male client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than: a. 0.21 b. 0.35 c. 0.5 d. 0.7

Answer C. An FO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air F IO 2 0.18 to 0.21.

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a. The system is functioning normally b. The client has a pneumothorax. c. The system has an air leak. d. The chest tube is obstructed

Answer C. Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? a. Restricting fluid intake to 1,000 ml/day b. Enforcing absolute bed rest c. Teaching the client how to perform controlled coughing d. Administering prescribed sedatives regularly and in large amounts

Answer C. Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Myasthenia gravis b. Type 1 diabetes mellitus c. Extreme anxiety d. Narcotic overdose

Answer C. Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, and injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes mellitus may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and narcotic overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: a. Pleural effusion. b. Pulmonary edema. c. Atelectasis. d. Oxygen toxicity

Answer C. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Inhale quickly b. Inhale through the nose c. Hold the breath after inhalation d. Take two inhalations during one breath

Answer C. Instructions for using a metered-dose inhaler include shaking the canister, holding it right side up, inhaling slowly and evenly through the mouth, delivering one spray per breath, and holding the breath after inhalation.

Pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a. Encouraging the client to drink three glasses of fluid daily b. Keeping the client in semi-Fowler's position c. Using a high-flow Venturi mask to deliver oxygen as prescribed d. Administering a sedative as prescribed

Answer C. The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.

A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a. pH b. Bicarbonate (HCO3-) c. Partial pressure of arterial oxygen (PaO2) d. Partial pressure of arterial carbon dioxide (PaCO2)

Answer C. The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation.

A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is: a. High and expected b. Low and unexpected c. Normal and expected d. Uncertain and unexpected

Answer C. The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg. The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because the edema is in the interstitium of the lung and is noncardiac.

On arrival at the intensive care unit, a critically ill female client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a. Fever b. Tachypnea c. Tachycardia d. Hypotension

Answer D. Hypotension, hypothermia, and vasoconstriction may alter pulse oximetry values by reducing arterial blood flow. Likewise, movement of the finger to which the oximeter is applied may interfere with interpretation of SaO2. All of these conditions limit the usefulness of pulse oximetry. Fever, tachypnea, and tachycardia don't affect pulse oximetry values directly.

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: a. alprazolam (Xanax). b. propranolol (Inderal) c. morphine. d. albuterol (Proventil).

Answer D. The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate

Answer D. The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: a. Lung vibrations. b. Vocal sounds. c. Breath sounds. d. Chest movements.

Answer D. The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say "99," the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. The nurse assesses breath sounds during auscultation.

Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: a. Exhale slowly. b. Stay very still. c. Inhale and exhale quickly. d. Perform the Valsalva maneuver.

Answer D. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions.

When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.

B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas.

A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? A. Ratio of hemoglobin and hematocrit. B. Status of acid-base balance in arterial blood. C. Adequacy of oxygen transport. D. Presence of a pulmonary embolus.

B. Status of acid-base balance in arterial blood. The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells, or the presence of a pulmonary embolus.

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels Explanation: Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

HCO3

Bicarbonate 22-25 carried in the blood mainly by c02 above 25 = acidosis more acid below 22= basic alkalosis

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. C. Encourage coughing and deep breathing to clear the airway. D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min.

D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next?

Mark the area with a skin pencil at the outer periphery of the crackling. Explanation: This crackling sensation is subcutaneous emphysema. Subcutaneous emphysema is not an unusual finding and is not dangerous if confined, and the nurse should mark the area to detect if the area is expanding. Progression can be serious, especially if the neck is involved; a tracheotomy may be needed at that point. If emphysema progresses noticeably in 1 hour, the HCP should be notified. Lowering the head of the bed will not arrest the progress or provide any further information. A tracheotomy tray would be useful if subcutaneous emphysema progresses to the neck. Subcutaneous emphysema may progress if the chest drainage system does not adequately remove air and fluid; therefore, the system should not be turned off

Which of the following interventions would assist a patient with chronic obstructive pulmonary disease (COPD) to improve lung expansion? 1. Instruct in abdominal breathing 2. Provide oxygen 4 liters nasal cannula 3. Teach/Encourage pursed lip breathing 4. Deep breathing and coughing

• 1. Instruct in abdominal breathing • Rationale: • Breathing exercises are frequently indicated for clients with COPD. Abdominal breathing improves lung expansion. Providing oxygen 2 liters per nasal cannula will not improve the client's lung expansion. Pursed-lipped breathing helps keep airways open by maintaining positive pressure. Deep breathing and coughing should be done every 2 hours to help keep the airway clear and prevent the pooling of secretions,not to improve lung expansion.

A Patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. The nurse would identify which of the following diagnoses as being a priority for this client? 1. Impaired Gas Exchange 2. Ineffective Tissue Perfusion 3. Anxiety 4. Impaired Physical Mobility

1. Impaired Gas Exchange. • Rationale: • A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing impaired gas exchange. This would be the priority for the client at this time. The client may ineffective tissue perfusion; however, this is not the priority. The client may be experiencing anxiety; however, this is not the priority at this time either. There is not enough information to determine whether the client is or is not at risk for immobility. • Nursing Process: Diagnosis • Cognitive Level: Analyzing • Client Need: Physiological Integrity • Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with pulmonary embolism.

A Patient with chronic obstructive lung disease is prescribed oxygen 24% 2 L/ min. The nurse realizes the best way to provide oxygen to this client would be with a: 1. Nonrebreather mask. 2. Nasal cannula. 3. Face mask. 4. Venturi mask.

2. Nasal cannula Rationale: The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Applying Learning Outcome: 6. Explain management of respiratory health and prevention of respiratory illness.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia Explanation: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation

Which nursing goal is a priority for the nurse planning care for a client immediately after a total laryngectomy?

Maintain a patent airway. Explanation: Maintaining a patent airway is the priority nursing goal in the immediate postoperative period. The client's ability to cough and deep breathe is impaired because the glottis has been removed. Providing nutrition, preventing hemorrhage, and reducing strain on suture lines are important nursing goals, but maintaining a patent airway is the priority.

normal breath sounds

Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), the lung shape, up and down the ribs bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds, close to core of the sternum

Which of the following instructions should you include in your discharge teaching plan for Mr. Fenske? Select all that apply a. Avoid persons with upper respiratory infections b. Eat three large meals daily c. Practice pursed lip breathing Correct d. Use body powders for excessive diaphoresis e. Use over-the-counter inhalants as needed f. Clean respiratory equipment daily

a, c, f

When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected findings?

increased anteroposterior chest diameter Explanation: Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

normal parameters for ABG values

pH = 7.35-7.45 PaCO2 = 35-45 mm Hg bicarbonate (HCO3) = 22-26 mEq/L PaO2 = 80-100 mm Hg SaO2 = greater than 95%

expected respiratory outcomes for hospitalized patient

-Have improved lung expansion -Be able to mobilize secretions -Maintain a patent airway -Have improved activity tolerance -Maintain oxygenation saturations >90%, respirations between 12-20 -Cough and deep breathe q 2 hours

The nurse is planning the care for a patient with chronic obstructive pulmonary disease (COPD) experiencing Imbalanced Nutrition: Less than Body Requirements. Which of the following interventions would be appropriate for this client? 1. Encourage carbohydrate rich foods to provide needed calories for energy 2. Suggest the client eat 3 meals per day to maintain energy needs 3. Limit snacks 4. Encourage a diet high in protein and fats

4. Encourage a diet high in protein and fats • Rationale: • A diet high in protein and fats without excess carbohydrates is recommended to minimize carbon dioxide production during metabolism. Carbohydrate rich foods would increase the client's carbon dioxide production and worsen the symptoms of the disease. The client should be encouraged to eat frequent small meals, not 3 meals a day. The client should be encouraged to eat frequent snacks, not limit snacks.

The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? A. No observable respiratory difficulty or shortness of breath over the last 24 hours. B. A decrease in the amount of nasal drainage and sneezing. C. No sputum production, and a decrease in coughing episodes. D. Relief of an acute asthmatic attack.

A. No observable respiratory difficulty or shortness of breath over the last 24 hours. Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic agents (beta2 agonist) are used to relieve bronchospasm in an acute episode.

nasal cannula

An oxygen-delivery device in which oxygen flows through two small, tubelike prongs that fit into the patient's nostrils; delivers 24% to 44% supplemental oxygen, depending on the flow rate.

Which of the following assessment findings would suggest to the nurse that a Patient is at risk for alterations in perfusion? 1. Blood pressure 110/68 mmHg 2. Apical heart rate 80; radial beats per minute 68 3. Respiratory rate 20 per minute 4. Temperature 98.8°F

Answer 2. Apical heart rate 80; radial beats per minute 68. • Rationale: • The number of radial beats per minute is 12 beats slower than the apical rate of 80 per minute. This indicates weak contractions of the left ventricle and could lead to alterations in perfusion. The other assessment findings are within normal limits. • Nursing Process: Assessment • Cognitive Level: Analyzing • Client Need: Physiological Integrity

An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis b. Respiratory acidosis c. Overcompensated respiratory acidosis d. Combined respiratory and metabolic acidosis

Answer A. In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect.

A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? a. Inhales the mist and quickly exhales b. Removes the cap and shakes the inhaler well before use c. Presses the canister down with the finger as he breathes in d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed

Answer A. The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options B, C, and D are accurate instructions regarding the use of the inhaler.

A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respiratory

Answer A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate of 24 breaths/min

Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician.

A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increase oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray

Answer B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum

Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.

While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. b. Grasp the retention sutures to spread the opening. c. Call the respiratory therapy department to reinsert the tracheotomy. d. Cover the tracheostomy site with a sterile dressing to prevent infection.

Answer B. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options 1 and 3 will delay treatment in this emergency situation.

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min

Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.

An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury

Answer B. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids b. Having the clients take three deep breaths c. Asking the client to split into the collection container d. Asking the client to obtain the specimen after eating

Answer B. To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis? a. Bronchoscopy b. Sputum culture c. Chest x-ray d. Tuberculin skin test

Answer B. Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction. b. Notify the physician immediately. c. Stop the procedure and reoxygenate the client. d. Ensure that the suction is limited to 15 seconds.

Answer C. During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum

Answer C. If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? a. Administering atropine intravenously b. Administering small doses of midazolam (Versed) c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids

Answer D. After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after.

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination.

Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.

After undergoing a thoracotomy, a male client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? a. Heightened alertness b. Increased heart rate c. Numbness and tingling of the extremities d. Respiratory depression

Answer D. Respiratory depression is the most serious complication of epidural analgesia. Other potential complications include hypotension, decreased sensation and movement of the extremities, allergic reactions, and urine retention. Typically, epidural analgesia causes central nervous system depression (indicated by drowsiness) as well as a decreased heart rate and blood pressure.

A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration

Answer D. Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range? a. 1 to 2 mcg/ml b. 2 to 5 mcg/ml c. 5 to 10 mcg/ml d. 10 to 20 mcg/ml

Answer D. The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic.

What is the most significant modifiable risk factor for the development of impaired gas exchange? A. Age. B. Tobacco use. C. Drug overdose. D. Prolonged immobility.

B. Tobacco use. Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired gas exchange but are not as significant as tobacco use.

The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? A. A patient with asthma and severe shortness of breath. B. A patient undergoing a bronchoscopy for a biopsy. C. A patient with a pleural effusion requiring fluid removal. D. A patient experiencing a problem with a pneumothorax.

D. A patient experiencing a problem with a pneumothorax. When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy.

The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for a client?

Pneumonia Explanation: By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. There is presence of quiet, effortless breath sounds at lung base bilaterally. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Oxygen saturation level is 98%. f. Nail beds are pink with good capillary refill.

b, e, f

After the nurse has received change-of-shift report, which of these patients should be assessed first? Answers: a. A patient with pneumonia who has crackles in the right lung base b. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing c. A patient with possible lung cancer who has just returned after bronchoscopy d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

c

abnormal (adventitious) breath sounds

crackles range from soft to fine, to coarse. CRACKLES=RALES discontinuous heard on inspiration, indicate fluid in the lungs obstructive diseases/pneumonia, sign of pulmonary fibrosis, CHF, and pulmonary edema. FINE RALES/CRACKLES high pitched popping alveoli COARSE CRACKLES= RHONCHI low pitch rumbling, sputum in the airwarys, can clear with strong cough, patients have chronic bronchitis and cystic fibrosis. excess mucus, bubbling moist sounds. WHEEZE continuous sounds air thru narrow airway. HIGH PITCH WHEEZE= musical air through bronchospastic or edematous airways. Expiratory wheeze with asthma and COPD. Typically heard in upper airways need bronchodilaters, steroids. PLEURAL FRICTION RUM= grating sound due to the inflammed pleura rubbing against chest wall. Heard mostly on inspiration and listen over lower lateral anterior surfa STRIDOR IS THE WORST WHEEZE

A patient has undergone a rhinoplasty to correct nasal deformities resulting from trauma during an automobile accident. The nursing intervention that is most appropriate postoperatively is to Answers: a. teach the patient to use aspirin or acetaminophen to control the postoperative pain. b. remind the patient that the nasal packing will not be removed for several weeks. c. reassure the patient that the nose will look normal when the swelling subsides. d. instruct the patient to keep the head elevated for 48 hours to minimize swelling.

d

While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 92% to 85% while the patient is ambulating in the hallway. Which action should the nurse take next? a. Notify the health care provider. b. Document the response to exercise. c. Encourage the patient to pace activity. d. Administer the PRN supplemental O2.

d. Administer the PRN supplemental O2.

health promotion strategies for those at risk for oxygenation problems

influenza vaccine (annually) pneumonia vaccine (indicated for those at risk, including the elderly, chronic illness, nursing home residents, children under 23 months, revaccination after age 65) -adequate nutrition -fluids -avoid crowds and ill persons -environmental protection (furnaces, smoke, wood stoves, pets, automobile exhaust, CO) -humidity

A client has a positive reaction to the Mantoux test. The nurse interprets this reaction to mean that the client has:

been exposed to Mycobacterium tuberculosis. Explanation: A positive Mantoux skin test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. A positive Mantoux test does not mean that the client has developed resistance. Unless involved in treatment, the client may still develop active disease at any time. Immunity to tuberculosis is not possible.

nursing diagnoses related to oxygenation

-Ineffective Airway Clearance -Impaired Gas Exchange -Ineffective Breathing pattern -Activity Intolerance -Risk for Infection

care management interventions used in the treatment of impaired gas exchange

1. assess for lung sounds, vital signs, oximetry, and ABGs 2. administer oxygen (titrate to keep O2 saturation above 90% unless COPD patient) 3. collaborate with respiratory therapy if different O2 delivery system needed 4. increase HOB, CDB, incentive spirometry, suction PRN, rhonchi 5. early ambulation, adequate hydration to liquefy sections 2-4 liters/day 6. postural drainage to prevent infection

interpretation of ABGs

1. classify pH (acidic or basic) 2. assess PaCO2 3. assess HCO3 4. determine if compensation is occurring 5. If pH is abnormal, identify what is the primary disorder 6. determine if oxygenation problem by looking at PaCO2

A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitations? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis

Answer A. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?

Acute respiratory distress syndrome (ARDS). Explanation: ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client's chances of recovery. The oxygen levels of clients with hospital-acquired pneumonia, hypovolemic shock, or asthma would be expected to improve with oxygen administration.

A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? a. Activity intolerance related to fatigue b. Anxiety related to actual threat to health status c. Risk for infection related to retained secretions d. Impaired gas exchange related to airflow obstruction

Answer D. A patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis. The other options also may apply to this client but are less important.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as:

Cheyne-Stokes respiration. Explanation: Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea

venturi mask

FiO2 24-55%; 4-12 L of oxygen; can be helpful in the treatment of COPD because specific amount of oxygen can be delivered; a medical device to deliver a known oxygen concentration to patients on controlled oxygen therapy

postural drainage positions

Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. *High Fowler's position is used to drain the apical sections of the upper lobes of the lungs. *Placing the patient lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the patient in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position, on a table flipped almost upside down. assists in draining the lower lobes of the lungs

A nurse is caring for a client who recently underwent a tracheostomy. What is the nurses first priority when caring for this client?

Suctioning to keep the airway patent Explanation: Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging the client to cough and breathe deeply, and turning the client are important actions, but are not the priority

partial rebreather mask

a device used in medicine to assist in the delivery of oxygen therapy. An NRB requires that the patient can breathe unassisted, but unlike low flow nasal cannula, the NRB allows for the delivery of higher concentrations of oxygen; FiO2 60-80% oxygen; deliver 10-15 L oxygen

An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important?

applying an oximeter and initiating respiratory therapy Explanation: Clients with cystic fibrosis commonly die from respiratory problems. The mucus in the lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be prescribed, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring adequate respiratory function.

A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report which adverse effect?

irregular heartbeat Explanation: Irregular heartbeats should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia

A client appears flushed and has shallow respiration. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance?

respiratory acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The PaCO2 value of 49 mm Hg is elevated. The HCO3- value of 24 mEq/L is normal. The client is in uncompensated respiratory acidosis. Hypoventilation and a flushed appearance are additional clinical manifestations of respiratory acidosis

simple face mask

used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 35% to 50% FIO2. This is contraindicated for patients with carbon dioxide retention because retention can be worsened. Flow rates should be 5 L or more to avoid rebreathing exhaled carbon dioxide retained in the mask.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag